Autologous (with your own tissue) flap procedures are more complex and require different surgical skills than implant reconstruction, but they produce breasts that feel more natural because they're made of living tissue.

Like direct-to-implant reconstruction (but unlike reconstruction involving expansion), flap procedures form full-size breasts during the initial operation. If revisions are required to refine breast shape or position, a shorter procedure is performed a few months later when the new breast has settled into position and swelling has diminished. New nipples can also be made during the same operation. The new nipples and areolae are then later tattooed.

Tissue flap reconstructionTissue flap reconstruction creates new breasts that look and move naturally, because they're made of your own living tissue.

Your own skin and fat can be transferred from your abdomen, back, upper or lower buttocks, hip ("love handles), or thighs and moved to the chest to create new breasts after mastectomy. More traditional flap reconstruction uses fat, skin and muscle from the abdomen or back; this can sometimes result in lost strength at the donor site. Improved, more sophisticated procedures use only fat and skin, and do not sacrifice muscle to recreate a breast.

Advantages of flap reconstruction

New breast is made of your own tissue

Start-to-finish timeline is usually shorter than traditional implant reconstruction with expanders.

Not susceptible to problems that are inherent with implants

Improves contour at donor site, especially hips and abdomen

Results last a lifetime

Disadvantages of tissue flap reconstruction

Scars an additional part of the body

Some procedures sacrifice muscle

Surgery and recovery are lengthier than implant procedures

Typically requires a second-stage revision surgery

The area surrounding the donor site incision may remain permanently numb

Types of flaps used for breast reconstructionBreasts created from flaps need a healthy blood supply to survive; this can be accomplished by several procedures, all of which are defined by the method of harvesting the blood vessels that feed the flap.

Attached flap (attached or pedicled TRAM, latissimus dorsi) surgeries free an area of skin, fat and muscle from the back or the abdomen, which is then tunneled under the skin to the chest and shaped into a breast. (Flaps removed from the abdomen are essentially the same as a tummy tuck, except the removed tissue is used to create a new breast instead of being discarded.) The new breast remains connected to its original blood supply (so it is "attached"). The downside to this technique is that it removes a perfectly health muscle, which increases recovery time and in some women, compromises subsequent functionality at the donor site.

Free flaps (free TRAM) are complete transplants. A flap of skin, fat, blood vessels, and a small portion of muscle surrounding the blood vessels are transplanted from the donor site to the chest; the tiny blood vessels in the flap are then attached to blood vessels in the chest. This requires the skill of a microsurgeon who uses special magnifying instruments to reconnect the blood vessels.

Perforator flaps are often referred to as the gold standard of natural tissue reconstruction because they are the most advanced type of breast reconstruction, creating breasts with skin and excess fat while preserving full muscle function. The muscle is dissected, rather than removed, to extract the blood vessels feeding the tissue used to create the breast. Perforator flap reconstruction requires different skills and specially-trained microsurgeons who carefully and precisely extract delicate blood vessels feeding the flap and reconnect them in the chest. Fewer surgeons are qualified or experienced with perforator flaps, so if you're interested in this technique, you may need to travel. Although most surgeons continue to perform reconstruction with attached flaps, perforator flap reconstruction is increasingly available as more surgeons are trained and become experienced with this advanced technique.